Form Ddd-1257aforpf - Discharge/transition Checklist For Individuals With High Risk Behavioral Challenges
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DDD-1257AFORPF (12-05)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Developmental Disabilities
DISCHARGE/TRANSITION CHECKLIST FOR INDIVIDUALS WITH HIGH RISK BEHAVIORAL CHALLENGES
INDIVIDUAL’S NAME (Last, First, M.I.)
DATE
EXPECTED MOVE-IN DATE
YES
NO
N/A
1. Has a one page emergency contact plan been developed? (Attach document)
2. Have all staff been oriented to the emergency contact plan?
3. Did direct care staff participate in the Person Centered Planning process?
a) If no, have direct care staff been oriented to complete planning packet?
4. Did pre-placements visit(s) occur? If so, how many?
5. Was a detailed description of visits provided by provider agency?
6. Has the environmental safety check been completed?
7. Has a schedule for the day of discharge been set up?
8. Has a daily routine been developed?
9. Has a weekly schedule been developed?
10. Have all staff who will work with the person received CIT training?
11. Has the team written the RBHA crisis plan with the RBHA case manager?
12. Has the RBHA crisis plan been entered into the RBHA crisis computer system and/or shared with appropriate RBHA providers?
13. Is medical care plan in place?
a) If yes, have staff been trained in the medical care plan?
14. Has a completed or initial behavior treatment plan been developed and/or revised?
15. Have staff been trained in the behavior treatment plan?
16. Has a Police Protocol been developed?
17. Have psychiatric services been set up for after discharge?
18. Is a 30-day supply of medications available upon discharge?
19. Are phone numbers for the psychiatrist, therapist and primary care physician and health plan contact person posted at the home?
20. Are all applicable crisis numbers posted at the home?
21. Neighborhood public relations plan?
22. Has it been clearly defined who within the agency staff are to call in an emergency situation?
23. Plan for monitoring placement for the first
weeks of placement. (Attach document)
24. Clearly defined criteria for when core team needs to reconvene? Person responsible for reconvening the team?
25. Was a full family history obtained for the individual?
26. Were any risk assessment tools used during the planning meeting?
Date of the next status meeting:
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